Wednesday, August 31, 2016


ObamaCare Not as Bad as It Sounds
It’s not as bad as it sounds.
Mark Twain, commenting on Richard Wagner’s music

ObamaCare may not be as bad as critics make it sound. It has insured 20 million previously uninsured Americans by subsidizing them in the health exchanges or moving them into Medicaid. 
But critics say it sounds  bad because taxpayers must carry the load of the subsidies and Medicaid.  Not only that, but unsubsidized consumers face an average of 23% increases in premiums in 2017 (sometimes 50% to 62% spikes in some states) and deductibles sometimes exceeding $800 before they can even see the doctor.  And those same consumers have in increasingly limited choice of doctors, hospitals, and health plans.
Thoughtful taxpayers, looking ahead, are asking, “How are we and our children  going to pay for a $20 trillion nation debt and $100 million in promised Medicare, Medicaid, Social Security and other entitlements after President Obama leaves office?”
While contemplating this and other questions,   consumers might want to commentaries like the following.

Obama Sabotages Obamacare

By Grace-Marie Turner
Forbes | August 29, 2016

As health insurers head for the exits, Americans who have been whipsawed by ObamaCare may get whacked again this fall:  First, they were thrown off private plans that were declared illegal, then they were forced into the ObamaCare exchanges, and now they could face the prospect of being shut out of coverage through their exchanges entirely for 2017.

In Arizona’s Pinal County, for example, no insurers are offering coverage through the exchange. While decisions won’t be final until next month, people in other counties could face a similar fate.

Elsewhere, millions of Americans will have a “choice” of just one carrier, especially in rural areas. It’s likely that Alabama, Alaska, and Oklahoma will have only one health insurer selling individual coverage on their exchanges next year. South Carolina and most of North Carolina could join that list as well.

Nearly one-third of the nation’s counties are likely to have just one insurer offering health plans on the exchanges next year: Last year, 50 Texas counties had only one insurer offering individual plans, according to data from the Texas Department of Insurance. Next year, Texans in 57 counties will have only one choice.  Exchange customers in many Florida counties will be offered only the Blues plans.

United Healthcare, Humana, and some Blues plans were the first start the exodus from the ObamaCare exchanges.  But when Aetna CEO Mark Bertolini announced in mid-August that his company will dramatically reduce its individual public exchange participation to just four states, it created an earthquake.

Aetna had been all in for ObamaCare, investing billions to offer coverage through the ACA exchanges. But after losing $430 million in this market since January 2014, Bertolini had to answer to his shareholders.

Insurers are pulling out largely because the exchange risk pools are getting worse, not better as the White House had promised.  They are losing money and see little or no prospect for the bleeding to stop.

The sicker risk pools mean coverage will be much more expensive next year with the carriers that remain.

According to ACAsignups.net, premium rate increases being requested by health insurance carriers nationwide for 2017 average 23% (much higher than a more selective Kaiser Family Foundation survey showing only a 9% increase).

Some consumers face even higher increases: BlueCross BlueShield of Tennessee received a 62% premium increase after documenting losses of $500 million on its exchange business over the last three years. Texas Blue Cross has filed for a 58% increase for its 603,000 exchange policyholders after reporting $1.2 billion in losses on these plans over two years.  In Pennsylvania, High Mark Blue Cross is asking for an average 41% increase.

Tennessee’s insurance commissioner says the exchange in his state is “very near collapse.” Tennessee either had to approve the requested increases or see companies drop out.

ACA supporters say exchange enrollees will largely be shielded from these increases because their coverage is subsidized. But someone is paying, and it is the beleaguered taxpayer.  Further, half of those in the potential individual health insurance market aren’t eligible for subsidies and would have to pay these exploding costs in full.

The higher premiums will drive even more healthy people away from the exchanges and leave costs even higher for the remaining (sicker) population. In the ObamaCare plan with the lowest premium—the Bronze plans—the average individual deductible for 2016 is $5,765. For a family plan, the deductible is $11,601. A growing number of healthy people figure they might as well be uninsured as pay high premiums for policies with such expensive deductibles.

The Obama administration has only itself to blame for the ObamaCare failures—first for jamming this bill through Congress despite warnings that the structure of the bill was an economic disaster, and then for exacerbating the breakdown through its regulatory dictates.  The ACA was sold on the pretense that we could have a private, competitive market for health insurance, but the law and subsequent regulations put the industry in a straightjacket, with rules at every turn that undermined the industry’s ability to offer attractive, competitive products.

The president over-promised on what his law would be able to do—saying it would dramatically cut health insurance costs for middle-income Americans while assuring them they could keep their coverage and their doctors.  His administration tried to patch over the serious political problems with the law—and cover for the broken promises—with whack-a-mole regulatory fixes that have only worsened them.

Now, exchange coverage is threatened because the costs of expensive, sick enrollees are not being offset by a greater number of healthy members.

Clearly, the president’s own policies are driving people away from ObamaCare.

The Congressional Budget Office expected ACA enrollment to reach 21 million this year, but the actual number likely will be only half that. That is one of the main reasons for the huge premium increases the remaining companies are forced to request.

The law required insurers to misprice risk—charging older, sicker people less and younger, healthier people more. Young adults have balked at paying up to 75% more than their actual cost so a 64-year-old can pay 13% less. No amount of regulatory tinkering can fix this unstable economic model.

The flawed and even illegal subsidies to insurers through reinsurance payments to insurers are not enough to make up for their losses, as documented in research by health policy experts Doug Badger, Brian Blase, Ed Haislmaier, and Seth Chandler.

Some critics say that insurers are happy with being the only player left in a state or county.  But that means they are the magnet for all of the high-risk patients with no ability to spread the loss, leading to even larger losses and higher prospective premiums.

The next president will inherit this mess.  Those who supported this disastrous and unworkable government intervention into the marketplace now say we need more government to fix the problems government has created. They believe the solution is to pour more taxpayer dollars into subsidies for individuals and insurers and to expand government even further through a "public option." More big government and more subsidies to insurers will not solve the underlying and fundamental problems with the law.

The reality is that if Republicans hold even one house of Congress, they will be very reluctant to pass any "fixes" to the program and will not create a public option, especially after the cascade of co-op failures built on the public-option model.

Instead, Republicans will look to advance elements of their own Better Way plan and will work to garner bipartisan support.There are areas of potential compromise:  Reconfiguring ACA tax credits into advanceable tax incentives paid in monthly installments to health-care consumers themselves.  The credits could be used to pay for health coverage that consumers want rather than policies they are forced to purchase by the federal government. Insurance would be regulated by states to give consumers more coverage options with more sensible regulations.

Instead of the highly-unpopular individual mandate in ObamaCare, Republicans would provide strong incentives for people to stay insured through “continuous coverage protection.”  States could gain more control over Medicaid to give them an incentive to spend federal and state dollars on this program in ways that provide better access to care than the current balkanized program does.

We need to think more broadly about solutions, making sure that people getting coverage now are protected, that those not buying or obtaining coverage have greater incentives to participate, and that the program is financially sustainable.

Grace-Marie Turner is president of the Galen Institute, a non-profit research organization focusing on free-market ideas for health reform. www.galen.org

 

 

Tuesday, August 30, 2016


ObamaCare Transformation Difficult and May Fail
Life is short, the art long, opportunity fleeting, experiment treacherous, judgment difficult.
Hippocrates (460-377 BC)
If Hippocrates were alive today,  he might be describing ObamaCare.
Its life will be short if Republicans win election and repeal ObamaCare, the opportunity for implementation will be fleeting if health exchange market assumptions continue to collapse,  its experiments with doctor payments and regulation will be treacherous as physician shortages mount and doctors refuse to accept more Medicare and Medicaid patients,  and if its judgments of how to fix it if the new Congress does not pass a Public Option provision.
At least that’s how I interpret today’s health care news.

·         “As ObamaCare Choices Shrink, Feds Face Consumer and Political Backlash,”  USA Today

·         ObamaCare Markets Are in Trouble: What Can Be Done,” 

New York Times 

·         “ObamaCare Economic Assumptions Collapse, Real Clear Politics

It’s really not as complicated as it is sometimes portrayed.  Insurers  need to make a profit to stay in business.   To make a profit,  insurers need the right mix of the healthy and the sick and the young and the old.   That mix is not forthcoming.  Major insurers – United, Aetna, and Humana – are pulling out of markets.   Government-run Consumer Operated and Oriented Plans are going bankrupt.  For consumers,  choices are disappearing,  prices are rising, markets are too small to predict profitable premiums, the rules are too complicated to comprehend,  too few people , half of what predicted, are joining the exchanges,  and the government’s economic assumptions, that consumers would welcome government intervention with subsidies for the have-nots and higher-taxes for the haves.
There’s another factor as well.  A country-wide health care transformation with disruption and lower revenues for most health care providers is not progressing as planned.  Many clinicians and hospitals are not cooperating or are resisting its provisions.   As Richard Bohmer of the Nuffield Trust in London observes,  a health care transformation is hard work (New England Journal of Medicine, August 25, 2016).    Such a transformation  requires  redesign of the entire system, the redesign teams are typically led by clinicians “Clinician-led teams take control of patient-facing organizations subsystems and reform clinical protocolas and operations and make modifications, review performance data and make modifications.. and actively create the local system needed to provide the best possible care.”  This sounds good in theory, but in practice,  many clinicians distrust government,  revolt against protocols, guidelines, and algorithms robbing them of their autonomy and income ,  and do not see quality and efficiencies  promised by reformists.   “The most substantial hurdle,” to health care reform, “ is a change in mindset.”  That change has not yet occurred among most of America’s  independent physicians in private practice.

 

 

 

Sunday, August 28, 2016


California -  A Wonderful  Place to Live
California’s a wonderful place to live – if you happen to be an orange.
Fred Allen (1894-1956), American Comedian
California is a wonderful place to live – if you happen to like warm weather, are a Democratic politician,  aspire to be an actor or television star,  crave  to be part of the California high-tech Silicon Valley Community,   if you are of Hispanic heritage – 30% of California speak Spanish as their primary language)or if you’re an observer of the good of ObamaCare – the number of uninsured there has dropped by 40% - and the bad – premiums are scheduled to go up an average of 13% in 2017.
Although the California economy is the 6th largest in the world if you think of it as a nation,   life is not so wonderful for small business,  who are exiting the state in record numbers to adjoining states and places like Texas and Florida.    The reasons for their departure are self-evident – the nation’s highest personal income tax at 13%,  the most regulated business sector,   a high cost of living and property,   fear of wild fires and shortage of water during its record drought, and unusually heavy health care expenses, which are causing big insurers to pull out of the state.
Still California for most  people remains  a great place to live.  It has over 39 million residents ,  a $2.4 trillion economy,  world class universities like Stanford and the University of California,  and the U.S.’s most widely known and admired private health care plan in Kaiser Health Care. And it’s a huge climatically diverse state, the 3rd largest geographically after Texas and Alaska.   You can always find something in California to like and to escape to,  it’s a great place for oranges,  other fruits, and nuts,, and for servers, transistors, and apps.   You have a choice: love it, move elsewhere inside it,  or leave it.

Saturday, August 27, 2016


The Internet Monster
What a monster have we created with the Internet?   Today news  indicates that hackers have targeted mobile cell phones to attack banks and their customers.   The Internet is reshaping our society, causing us to look down at our smart phones and tablets, not into each others’ eyes, robbing us of our privacy,  and stealing  our identity and our money. Now we are even wandering the streets,  in search of any monster, Pokemon-Go.
In the short span of 20 years, the Internet Monster has replaced the Cookie Monster.   If you’ll recall, the Cookie Monster was created to appeal to children on Sesame Street. Its mantra was: “Me want cookies! Me eat cookies! Me eat anything and everything!”  Its appetite was insatiable.  It ate in broad daylight.  It ate a night.   It ate behind closed doors. It  ate your breakfast, lunch, and dinner.  It ate 24 hours a day.  It was always raiding your personal cookie jar.  It ate things you were not even aware.
The Internet Monster puts the Cookie Monster to shame.  It obesses the entire population.  Its appetite for your total attention  is insatiable.    It is everywhere – on your personal computer, your tablet,  your smart phone, on corporate and government website, amazon, facebook,  Instagram,  Internet servers , even in the “Cloud,” anywhere and every where you look for information, a loan, for something to buy, borrow, or steal, anything that forwards, delivers, and stores information.
Everybody is interconnected,  which is not the same as being interoperatible .  The Internet is like a uncoordinated electronic octopus with countless tentacles, unconnected to any central brain.  It has common mobile operating systems  - like Apple Inc’s iOS and Alphabet Inc’s Android – but even these systems, like the federal government’s systems,  are vulnerable to hackers.
The Internet Monster’s message system is email which has largely  replaced  snail mail,  in the process nearly bringing down the U.S. Postal System.   Almost anyone can hack email, like  convicted sex offender Julian Assuage of Wikileaks.
You can never really hide what you text  on emails.  You can try to hide it, destroy it,   bleachbit it.  Email is the Hacker’s Paradise, that golden treasury and trough of embarrassing  information.
The Internet Monster has many faces and interfaces and interstices.    It produces information overload, spam, malware, malicious spoofs,  global boom blasts,  electronic fatigue and exhaustion.
The Internet Monster has transformed politics.   You can never hide what you have taxted.  Iti is always somewhere in storage.  It is the fodder and grist of controversie.  It is an integral part of vast left-wing and right-wing conspiracies. It may yet undo Hillary Clinton’s campaign – through some September timebomb or Donald Trump’s campaign – through a maladroit tweet,
It has destroyed or displaced multiple industries - brick and mortar stores,  the publishing industries - books and newspapers,  clerks and secretaries and middle manager,  even entire towns. like Rochester, New York, and its film industry.
It has changed personal relationships.   You can no longer engage in  ordinary open conservations  and llo into some’s eyes or read their body language.  You must text.  You must carry your mobile device wherever you go or whatever you’re doing,  like walking, eating, or driving.  You must constantly focus on the screen, look down rather than up,  connect electronically,  to make sure you do not miss anything, no matter how trivial,  as long as your are paying allegiance to the Internet Monster,  which dominates your every waking moment or piling up email messages while you sleep.

Thursday, August 25, 2016


 


Is MACRA the Final Blow for Small Independent Practices?
The following article is from Kaiser Health News?   It raises this fundamental  question -  does MACRA(The Medicare Access and CHIP Reauthorization Act) – which discourage fee-for-service and encourages ACOs (Accountable Care Organizations  and APMs (Alternative Payment Models ) spell the end of small private practices which depend on Medicare patients for their existence?
Doctors Raise Concerns For Small Practices In Medicare’s New Payment System
By Steven Findlay August 25, 2016
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“We’re struggling to survive,” Gross, 47, said. “Our kind of practice is dying in this country, and medicine itself is changing so rapidly that doctors everywhere seem to be burning out.”
Indeed, in their professional journals, at conferences, on social media and health care blogs, and in comments to federal regulators, the nation’s doctors are expressing growing anger and frustration.
The focal point of their angst is a 2015 federal law that changes the way Medicare pays doctors.logo washingtonpost110
The Medicare Access & CHIP Reauthorization Act — is Congress’ boldest step since the 2010 Affordable Care Act to push the health care system to reward quality over quantity. It replaces a reimbursement system that was widely criticized by doctors and regularly ran into budget problems on Capitol Hill.
“This is a big change, we know,” said Tim Gronniger, deputy chief of staff at the Centers for Medicare & Medicaid Services. But, he added, “the current way we pay doctors incentivizes them in bad ways — to waste resources, for example.”
The law has bipartisan support and does not come with the political tension of the ACA. Still, the Obamacare battles have shown that broadly reshaping health care is no easy task.
Poor and wasteful care accounts for a quarter to a third of all health care spending, according to the National Academy of Sciences’ Institute of Medicine.
That would total between $875 billion to $1.1 trillion of the $3.5 trillion expected to be spent on health care in the U.S. in 2016.
The law sets up two payment tracks. All doctors must choose one, except for those who see too few Medicare patients or whose income from Medicare is too low.)
On one track, doctors whose performance and quality of care exceeds benchmarks get bonuses up to 4 percent of their total Medicare reimbursements. Those will start in 2019, based on evaluations of care delivered in 2017, and will rise a maximum of 9 percent by 2022. By the same token, physicians who score poorly on quality benchmarks — which include requirements for the use of electronic health records — face penalties at the same levels.
The amount the government spends on the bonuses — estimated at $833 million for 2019 — must be balanced by the penalties, keeping the program “budget neutral.” However, Congress also authorized an extra $500 million a year bonus pool through 2024 for doctors judged “exceptional.”
On the other path, doctors choose to join larger practices or organizations — called “alternative payment models” — that would be held accountable for the quality of care delivered by all the doctors in the organization.
Congress’ intent, experts say, was to push doctors to join such larger organizations, which generally are considered better equipped to manage and coordinate care, improve quality and lower costs than are solo or small groups of doctors.
Doctors get a 5 percent annual bonus between 2019 and 2024 if they join an alternative payment organization, along with any bonuses or penalties the organization chooses to mete out.  Starting in 2026, doctors in such organizations will continue to get a small annual payment adjustment from Medicare that’s larger than doctors who don’t choose the alternative path — 0.75 percent versus 0.25 percent.
Physicians’ concern is that the new payment system — laid out in a 962-page proposed regulation in April — will put doctors in solo or small practices at high risk of incurring payment penalties and will push thousands into larger practices and alternative payment organizations.
“The ways it’s structured now, the large practices will do well and the small practices will do badly,” said Paul Ginsburg, director of the Center for Health Policy at the Brookings Institution.
During a public comment period, the American Medical Association and dozens of other physician trade organizations and every state medical association said the system needs to be simplified and must “accommodate the needs of physicians in rural, solo, or small practices in order to enhance their opportunities for success and avoid unintended consequences.”
One of those unintended consequences, the AMA says, is that penalized doctors would limit the number of Medicare patients they see, or drop Medicare.
“I have no idea what I’m going to do yet,” says Dr. Jean Antonucci, a primary care physician who has a solo practice in Farmington, Maine. Half her patients are covered by Medicare. “If I’m going to lose money, I’ll have to see what my options are. I don’t want to limit how many Medicare patients I see."
“I don’t want to spend the bulk of my time doing paperwork or collecting data on my patients,” said Jean Antonucci. (Courtesy of Jean Antonucci)
Antonucci and Gross say they want to preserve their small practices. “I don’t want to spend the bulk of my time doing paperwork or collecting data on my patients,” said Antonucci. “That’s what the doctors in my community who are employed [in larger groups] seem to spend most of their time doing.”
Some experts agree that the burden to report quality-of-care to the government is significant.\
“We don’t yet have a good system to measure the performance of individual physicians,” says Robert Berenson, a physician and fellow at the Urban Institute and former director of Medicare payment policy for the federal government. “And yet we are going to peg billions of dollars in payment to such measurement. It’s a little crazy.”
A study published in March in the journal Health Affairs calculated the scope of that data collection now. It found physicians and their staffs spend $40,000 per doctor per year — $15.4 billion nationwide — collecting and reporting information about their care to Medicare, private insurers and others.
Gronniger says CMS has, in the proposed rule, scaled back the number of measures doctors must report. “We are eager to work through the issues doctors’ groups have raised,” Gronniger said.
Even so, the AMA and other physician groups are pushing CMS to delay the start for collecting quality-of-care information from  next January until at least July. Medicare administrators have pledged to issue final regulations by Nov. 1.
“This is all very complex,” said AMA President Andrew Gurman. “A lot of doctors are very frustrated … but we are committed to trying to make the new law work.

Wednesday, August 24, 2016


ObamaCare Endgame:  Achieve Savings by Redistributing Income from Specialists to Primary Care Physicians
 MACRA (Medicare Access and CHIP Reauthorization Act of 2015) which shifts traditional Medicare patients into risk-based reimbursement  by giving doctors incentives to join with hospitals to form  Accountable Care Organizations to share “savings” with hospitals and  to join organizations that employ primary care organizations  in order to achieve savings by reaching  measurable quality goals by reducing the specialty care referrals.

According to Robert Kocher, MD, and Anuraag Chigurapati, MS, at policy institutes at the University of California, Stanford, and Harvard,  the MACRA endgame  is designed to redistribute income to primary care physicians from specialists ("The Coming Battle over Shared Savings - Primary Care versus Specialists,"  New England Journal of Medicine,  July 14, 2016,)  In a sample chart in their article, the authors project MACRA could reduce incomes for diagnostic radiologists by $35,000 and cardiologists by $25,000,   thereby narrowing the average incomes of $284,000 of specialists versus $195,000 for primary care physicians. 

Will this MACRA scenario work in the real world?
Specialty care is by far the most expensive cost Medicare has to bear.    In the minds of CMS officials and progressive elistists,  at least 30% of  Medicare costs are unnecessary and can be traced to physician and hospital greed, which depend on specialty referrals as their major sources of revenue.  By curtailing specialty referrals,  theoretically one could save money by reducing hospital  days,  ER visits, lengths  of stay in skilled nursing facilities, and intensity of diagnostic testing and procedures  performed by specialties.
To accomplish the goals envisioned by CMS,   one simply needs to  measure the outcomes of Medicare populations  by measuring  “population health”,  by shifting risks to primary care physicians,  and by preaching the gospels of evidence-based medicine and “value” health , both of which are loosely defined as outcomes and quality control per doctors expended. 
The basic belief system here rests on a fundamental thesis of management,  “In God we trust, all others use data.”  If you impose enough regulations  and impose enough documentation rules,  somehow, somewhere, somehow,  government “savings” will be achieved.   Unfortunately,  Government bureaucracies have no history of achieving savings, and trust in government has reached  an all time low.
ACRA requires a leap of faith in government experts to do the job of reform, on the ability o0f government experts to analyze complex systems,  on sophisticated technocratic analysis, and government rule-writing on the most equitable solution to social  inequities.   

I am profoundly skeptical about MACRA.  It’s hard to understand, rests on non-commonsensical assumptions, and its bloated bureaucratic rules will raise costs.   Pitting primary care doctors against specialists will be psychological offensive t many doctors,  and it won’t raise quality since many consumers  regard specialty essential in many instances.